DOI: https://doi.org/10.

2298/SARH170428146R
UDC: 616.314.25/.26-085 149

ORIGINAL ARTICLE / ОРИГИНАЛНИ РАД

Effects of three types of functional appliances

in Class II malocclusion treatment – sagittal and
vertical changes
Vladimir Ristić, Neda Lj. Stefanović, Zorana Stamenković, Marija Živković-Sandić,
Vanja Stojić, Branislav Glišić
University of Belgrade, Faculty of Dental Medicine, Department of Orthodontics, Belgrade, Serbia

SUMMARY
Introduction/Objective Class II malocclusions are sagittal malocclusions characterized by a distal rela-
tionship of posterior teeth. Depending on the underlying problem, Class II malocclusions can be skeletal
or dentoalveolar. Class II malocclusion treatment modality will depend on the cause, severity, and age.
Growth modification is the best treatment option in growing patients with skeletal Class II malocclusions.
The aim of this study was to establish and compare sagittal and vertical skeletal and dental changes in
patients treated with the “M block” appliance, the Fränkel functional regulator, and the Balters’ bionator.
Methods The sample consisted of 70 patients diagnosed with skeletal Class II malocclusions (ANB > 4°)
and mandibular retrognathism (SNB < 80°). The patients were divided into three groups according to the
type of appliance. All the patients went through the standard diagnostic procedure (anamnesis, clinical
and functional analysis, study model, panoramic radiograph, and cephalometric analysis), and dental
and skeletal age was determined. Treatment effects were analyzed on study models and cephalograms
at the end of treatment.
Results All the appliances led to significant mandibular anterior movement and sagittal growth, which
reduced the ANB values. All three groups of patients presented with neutral growth pattern, upper inci-
sor retrusion, and lower incisor protrusion at the end of treatment.
Conclusion The results of this study indicate efficacy of all three appliances in skeletal Class II maloc-
clusion treatment.
Keywords: class II malocclusion; functional treatment; M block appliance; Fränkel appliance; bionator

INTRODUCTION adolescents and permanent dentition post-ad-

Class II malocclusions are sagittal malocclu-
sions characterized by a distal relationship
of posterior teeth. Depending on the under-
lying problem, Class II malocclusions can
be skeletal or dentoalveolar. Skeletal Class II
malocclusions are characterized by a distal
maxillo-mandibular relationship. This could
be a consequence of mandibular retrognathism
and/or underdeveloped mandible, maxillary
prognathism and/or overdeveloped maxilla,
or a combination of the two [1, 2]. Depend-
ing on the cause of the malocclusion, Class II
can be treated by growth modification, dental
camouflage, or orthodontic-surgical treatment.
Whenever there is a skeletal discrepancy, best
treatment option would be growth modifica-
tion. However, this treatment modality could
be used only if the patient is still growing [3,
4]. Growth modification treatment uses the pa-
tient’s residual growth in order to change jaw
dimensions and position and establish proper
occlusion. Ideal timing for this kind of treat-
ment would be just before the pubertal growth
spurt. Removable functional appliances are the
most commonly used appliances in children
and late-mixed dentition adolescents. Fixed
functional appliances are commonly used in
olescents, due to limited effects of removable
appliances and lack of compliance [4].
Growth modifying functional appliances fa-
cilitate change in the activity of different groups
of muscles by delivering forces to the jaws and
teeth, therefore affecting their function and
position [5]. Most commonly used functional
appliances are Andresen activator, twin block
appliance, Sander’s bite-jumping appliance,
Fränkel functional regulator, Balters’ bionator,
etc. A modification of the Sander’s bite-jumping
appliance made with the Schaneng screw (Den-
taurum GmbH & Co. KG, Ispringen, Germany)
instead of the Sander’s functional screw (Fores-
tadent Bernhard Förster GmbH, Pforzheim, Received • Примљено:
April 28, 2017
Germany) has been successfully used at the
Revised • Ревизија:
Department of Orthodontics, Faculty of Dental July 7, 2017
Medicine, University of Belgrade, for over a dec- Accepted • Прихваћено:
ade. This appliance, also known locally (in Ser- July 12, 2017
bia) by the name “M block” appliance, consists Online first: July 18, 2017
of an upper and lower removable appliance. An
expansion screw and the Schaneng functional
screw are built into the upper appliance. The
lower appliance contains an inclined plane that Correspondence to:
guides the functional screw and directs the man- Vladimir RISTIĆ
dible forward. The M block appliance (Figure Klinika za ortopediju vilica
Gastona Gravijea 2
1) is built according to the design suggested by 11000 Beograd
Sander for his bite-jumping appliance [6, 7]. vristic7@gmail.com
150
Figure 1. M block appliance
The aim of this study was to establish and compare sag-
ittal and vertical skeletal and dental changes in patients
treated with the M block appliance, the Fränkel functional
regulator (Figure 2) and the Balters’ bionator (Figure 3).
METHODS
The sample of this study consisted of 70 patients treated at
the Department of Orthodontics of the Faculty of Dental
Medicine, University of Belgrade. Inclusion criteria were
skeletal distal bite (ANB > 4°), mandibular retrognathism
(SNB < 80°), no previous orthodontic treatment, and ap-
propriate age (prepubertal growth spurt).
According to the type of appliance used in treatment,
subjects were divided into three groups: Group I: patients
treated with the M block appliance (30 subjects); Group
II: patients treated with the Fränkel functional regulator
type I (20 subjects); Group III: patients treated with the
Balters’ bionator type I (20 subjects).
All three appliances are indicated for treating growing
patients diagnosed with skeletal distal bite and mandibular
retrognathism.
Standard diagnostic procedure was performed, which
included anamnesis, clinical and functional examination,
study model analysis, panoramic radiograph analysis, and
cephalometric analysis. Dental age was estimated according
to the method developed by Demirjian et al. [8]. Skeletal
age was determined using the modified Cervical Vertebral
Maturation method described by Baccetti et al. [9]. Accord-
ing to age assessment, all patients were in the pre-pubertal
DOI: https://doi.org/10.2298/SARH170428146R
Ristić V. et al.
Figure 2. Fränkel functional regulator type I
Figure 3. Balters’ bionator type I
growth spurt period, which is a crucial prerequisite for
functional orthodontic treatment. The average chrono-
logical age of patients before the beginning of treatment
was 10 years and one month, and the average dental age
was nine years and five months. Skeletal age analysis of
pretreatment records revealed the following data: in Group
I, three patients were in stage 1 (10%), 22 patients in stage
2 (73%), and five patients in stage 3 (17%); in Group II,
nine patients were in stage 1 (45%), seven patients in stage
2 (35%), and four patients in stage 3 (20%); in Group III,
four patients were in stage 1 (20%), nine patients in stage
2 (45%), and seven patients in stage 3 (35%). The average
treatment time was 15 months in Group I, 20 months in
Group II and 22 months in Group III. The patients’ age,
treatment time, and sex distribution are shown in Table 1.
Cephalometric analysis
The following cephalometric parameters were used: I sagit-
tal parameters (angles): SNA – sagittal position of the max-
illa; SNB – sagittal position of the mandible; SNPg – sagittal
position of the chin; ANB – sagittal maxillo-mandibular
relationship; II maxillary and mandibular development pa-
rameters (linear distances): Snp to A’ – length of the maxil-
Srp Arh Celok Lek. 2018 Mar-Apr;146(3-4):149-156
Effects of three types of functional appliances in Class II malocclusion treatment – sagittal and vertical changes 151

lary corpus (C max); Go’ to Pg’ – length of the mandibular RESULTS

corpus (C mand); Cd’ to Go’ – length of the mandibular
ramus (R mand); Cd to Me – total mandibular length
(Mand); III vertical parameters (angles): SN/SpP – verti-
cal position of the maxilla; SN/MP – vertical position of the
mandible; SpP/MP – vertical maxillo-mandibular relation-
ship; IV type of growth: Bjork polygon (Σ = NSAr + SAr-
Go + ArGoMe); anterior to posterior facial height relation
(S-Go/N-Me × 100); V incisor position (angles): I/SpP –
upper incisor inclination; i/MP – lower incisor inclination.
All appliances (M block, Fränkel functional regulator
type I, and Balters’ bionator type I) were made accord-
ing to standard principles previously described in the lit-
erature [10]. Therapeutic effects of these appliances and
consequential changes were recorded on study models and
cephalograms at the end of treatment.
Statistical analysis
Mean values, standard deviations, minimal and maximal
values were calculated as a part of descriptive statistics. Sta-
tistical analysis included two-factor analysis of the variance
with repeated measuring, where the measuring was done in
relation to the factor time and the time and group allocation
factor. Monofactorial variance analysis was done using the
ANOVA, Boneferroni, and Student’s t-test for determining
the statistical significance of acquired differences.
This research was approved by the Ethics Committee
of the Faculty of Dental Medicine, University of Belgrade
(resolution number 36/6 issued on March 21, 2012).
I Sagittal parameters
The SNA angle decreased slightly after the M block ap-
pliance and Fränkel functional regulator treatment, and
increased significantly after bionator treatment. Two-
factor analysis of the variance with repeated measuring
was used to evaluate the treatment effect of three differ-
ent functional appliances on the sagittal position of the
maxilla in two different time periods (the beginning and
the end of treatment) and it was established that there
were no statistically significant changes in pre- and post-
treatment values. However, statistically significant changes
appeared when all three appliances were compared. The
SNB angle increased significantly in all three groups of
patients. Two-factor analysis of the variance with repeated
measuring revealed the influence of time on the SNB value
changes within groups. A statistically significant difference
was also noted when comparing all three appliances over
time. The SNPg angle also increased significantly after
treatment in all three groups. Two-factor analysis of the
variance with repeated measuring showed the influence of
time on the value changes before and after treatment, as
well as between groups over time (Table 2). The ANB angle
decreased significantly in all three groups. Statistically sig-
nificant differences were noted in the pre-treatment values
of parameters between Group I and Group II and in the
post-treatment values of parameters between Group I and
Group II, and Group II and Group III (Table 3).

Table 1. Age, treatment time, and sex distribution

Mean age (years, months) Treatment time Sex
Parameter Skeletal age
chronological dental (months) ♂ ♀
Stage 1 (10%)
M block
10 y 4 m 9y8m Stage 2 (73%) 15 13 17
n = 30
Stage 3 (17%)
Stage 1 (45%)
Fränkel
8y8m 9y2m Stage 2 (35%) 20 10 10
n = 20
Stage 3 (20%)
Stage 1 (20%)
Bionator
10 y 7 m 9y3m Stage 2 (45%) 22 9 11
n = 20
Stage 3 (35%)

Table 2. Values and statistical significance of changes – sagittal parameters SNA, SNB, and SNPg
Significancea Significancea
T1 T2 Δ (T2 - T1)
Parameter (difference between (difference between Significanceb/c Significanced
x ± SD x ± SD x ± SD
groups at T1) groups at T2)
SNA (°) p
M block n = 30 81.72 ± 2.97 81.63 ± 3.45 -0.08 ± 1.26 0.720
b
0.075
Fränkel n = 20 81.4 ± 2.52 81.25 ± 2.49 -0.15 ± 1.14 0.876 0.357 c 0.562
0.005*
Bionator n = 20 81.35 ± 2.66 82.55 ± 2.48 1.20 ± 1.96 0.013*
SNB (°)
M block n = 30 76.35 ± 3.22 77.48 ± 3.13 1.13 ± 1.40 0.000*
b
0.000*
Fränkel n = 20 74.7 ± 2.56 77.65 ± 2.46 2.95 ± 1.05 0.148 0.971 c 0.000*
0.000*
Bionator n = 20 75.5 ± 2.72 77.65 ± 2.68 2.15 ± 1.34 0.000*
SNPg (°)
M block n = 30 77.6 ± 2.79 78.56 ± 2.86 0.96 ± 0.99 0.000*
b
0.000*
Fränkel n = 20 76.5 ± 2.44 78.55 ± 2.64 2.05 ± 0.99 0.250 0.857 c 0.000*
0.001*
Bionator n = 20 76.5 ± 2.84 78.15 ± 2.70 1.65 ± 0.87 0.000*
*statistically significant difference; amonofactorial variance analysis; btwo-factor analysis of the variance, factor time; ctwo-factor analysis of the variance, factor
time * group; dt-test for paired samples

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152 Ristić V. et al.

Table 3. Values and statistical significance of changes – sagittal parameter ANB

Significancea Significancea Significanceb Significanceb
Significancec
(difference (difference (difference (difference
ANB (°) T1 T2 (difference within
between groups between groups between groups between groups
groups T1 and T2)
at T1) at T2) at T1) at T2)
M block n = 30 5.5 ± 0.81 4.38 ± 1.11 0.001* M vs. F 0.005* M vs. F 0.000*
Fränkel n = 20 6.6 ± 1.35 3.6 ± 1.23 0.005* 0.002* 0.114 M vs. B 0.154 M vs. B 0.000*
Bionator n = 20 5.9 ± 1.07 4.9 ± 1.23 0.086 F vs. B 0.002* F vs. B 0.004*
*statistically significant difference; aKruskal–Wallis test; bMann–Whitney test; cWilcoxon matched pairs test

Table 4. Values and statistical significance of maxillary and mandibular development parameters
Significancea Significancea
Parameter T1 T2 Δ (T2 - T1) (difference between (difference between Significanceb/c Significanced
groups at T1) groups at T2)
C max (mm)
M block n = 30 48.57 ± 3.28 49.80 ± 3.13 1.23 ± 0.72 0.000*
b
0.000*
Fränkel n = 20 49.30 ± 2.34 50.80 ± 2.39 1.50 ± 1.36 0.596 0.100 c 0.000*
0.011*
Bionator n = 20 49.23 ± 2.50 51.60 ± 2.98 2.37 ± 1.83 0.000*
C mand (mm)
M block n = 30 70.33 ± 5.37 72.02 ± 5.23 1.69 ± 0.85 0.000*
b
0.000*
Fränkel n = 20 71.23 ± 5.32 73.20 ± 4.72 1.97 ± 1.40 0.829 0.690 c 0.000*
0.168
Bionator n = 20 71.08 ± 6.09 72.05 ± 5.35 0.97 ± 2.69 0.122
R mand (mm)
M block n = 30 55.77 ± 3.63 57.50 ± 3.88 1.73 ± 0.93 0.000*
b
0.000*
Fränkel n = 20 55.10 ± 4.08 56.55 ± 3.43 1.45 ± 2.96 0.515 0.537 c 0.041*
0.796
Bionator n = 20 54.47 ± 4.09 56.45 ± 3.71 1.98 ± 3.33 0.016*
Mand (mm)
M block n = 30 108.02 ± 5.72 109.80 ± 5.78 1.78 ± 1.27 0.000*
b
0.000*
Fränkel n = 20 105.70 ± 5.16 108.40 ± 5.11 2.70 ± 3.21 0.212 0.442 c 0.001*
0.320
Bionator n = 20 107.75 ± 2.72 110.50 ± 3.28 2.75 ± 3.15 0.003*
*statistically significant difference; amonofactorial variance analysis; btwo-factor analysis of the variance, factor time; ctwo-factor analysis of the variance, factor
time * group; dt-test for paired samples

II Maxillary and mandibular development parameters III Vertical parameters

Maxillary corpus length increased significantly after treat-
ment in all three groups. Two-factor analysis of the vari-
ance with repeated measuring established a statistically
significant change in the pre- and post-treatment values of
the maxillary corpus length. Statistically significant chang-
es were also noted when comparing all three groups of
treated patients. Mandibular corpus increased significantly
after M block appliance and Fränkel functional regulator
treatment, while an insignificant change was established
after bionator treatment. Two-factor analysis of the vari-
ance with repeated measuring revealed statistically signifi-
cant influence of mandibular corpus length change within
groups over time. Mandibular ramus height increased
significantly in all three groups of patients. Two-factor
variance analysis with repeated measuring revealed the
influence of mandibular ramus length value changes with-
in groups over time. Total mandibular length increased
statistically in all three groups. Two-factor analysis of the
variance with repeated measuring showed a statistically
significant influence of total mandibular length change
within groups before and after treatment (Table 4).
The SN/SpP angle increased significantly after M block
appliance treatment, and insignificantly after Fränkel
functional regulator and bionator treatment. Two-factor
analysis of the variance with repeated measuring estab-
lished a statistically significant difference in value changes
before and after treatment, and a lack of significance when
comparing all three groups before and after treatment.
The SN/MP angle decreased insignificantly in group II,
while it increased significantly in groups I and III. Mono-
factorial variance analysis revealed statistically significant
differences between groups I and III before treatment.
Statistically significant differences were also noted when
comparing groups after treatment. Two-factor analysis of
the variance with repeated measuring established a statisti-
cally significant influence of value changes before and after
treatment, as well as between groups over time. Fränkel
functional regulator treatment resulted in a decrease of
the SpP/MP angle, while the M block and bionator treat-
ment resulted in an increase of the same angle. Statisti-
cally significant changes were present when comparing
post-treatment values between groups, while comparing
groups in pairs lacked significance. Two-factor analysis of
the variance with repeated measuring revealed statistically
significant differences between groups over time (Table 5).

DOI: https://doi.org/10.2298/SARH170428146R Srp Arh Celok Lek. 2018 Mar-Apr;146(3-4):149-156

Effects of three types of functional appliances in Class II malocclusion treatment – sagittal and vertical changes 153

IV Type of growth parameters
The sum of the Björk polygon angles increased in all
groups, the bionator group lacking statistical significance.
Two-factor analysis of the variance with repeated measur-
ing recognized the influence of all three types of appliances
on the increase at two points in time (before and after
treatment). There was no significant interaction between
the type of appliance and time, while a significant influ-
ence of time (before and after treatment) was confirmed in
patients within each group. The percentage of the anterior
to posterior facial height relation decreased, but none of
the appliances caused any statistically significant differ-
ences in the pre- and post-treatment values (Table 6).
V Incisor position
Upper incisors were uprighted significantly after treat-
ment in all three groups. Monofactorial variance analysis
revealed statistically significant changes in the I/SpP angle
after treatment, as well as between groups over time. Low-
er incisors were proclined significantly after M block and
Fränkel functional regulator treatment, while the bionator
group lacked statistical significance. Monofactorial vari-

Table 5. Values and statistical significance of vertical parameters SN/SpP, SN/MP, SpP/MP
Significancea Significancea Significancee Significancee
T1 T2 Δ (T2 - T1) (difference (difference b/c d
(difference (difference
Parameter Significance Significance
x ± SD x ± SD x ± SD between between between between
groups at T1) groups at T2) groups at T1) groups at T2)
SN/SpP (°)
M block n = 30 8.25 ± 4.39 9.10 ± 4.92 0.85 ± 1.32 0.001*
b
0.001*
Fränkel n = 20 8.90 ± 2.12 9.30 ± 2.13 0.40 ±1 .90 0.567 0.704 c
0.359
0.616
Bionator n = 20 9.30 ± 3.03 10.00 ± 2.96 0.70 ± 1.59 0.064
SN/MP (°)
M block n = 30 31.60 ± 5.56 32.50 ± 6.10 0.90 ± 2.20 0.033* 0.437 M vs. F 1.00 M vs. F
b
0.033*
Fränkel n = 20 33.85 ± 4.97 33.08 ± 5.31 -0.77 ± 2.29 0.021* 0.004* c
0.261 0.018* M vs. B 0.005* M vs.B
0.005*
Bionator n = 20 35.95 ± 5.19 37.85 ± 5.16 1.90 ± 2.53 0.003* 0.642 F vs. B 0.027* F vs. B
SpP/MP(°)
M block n = 30 26.58 ± 5.12 27.17 ± 4.79 0.59 ± 1.96 0.115 0.10 M vs. F
b
0.505
Fränkel n = 20 25.10 ± 5.61 23.90 ± 5.07 -1.20 ± 3.03 0.608 0.039* c
0.930 1.00 M vs. B
0.017*
Bionator n = 20 26.55 ± 6.10 27.85 ± 5.91 1.30 ± 3.51 0.114 0.058 F vs. B
*statistically significant difference; amonofactorial variance analysis; btwo-factor analysis of the variance, factor time; ctwo-factor analysis of the variance, factor time
* group; dt-test for paired samples; eBonferroni test

Table 6. Values and statistical significance of the type of facial growth parameters
Significancea Significancea
T1 T2 Δ (T2 - T1)
Parameter (difference between (difference between Significanceb/c Significanced
x ± SD x ± SD x ± SD
groups at T1) groups at T2)
Σ Bjørk (°)
M block n = 30 393.50 ± 4.68 395.80 ± 3.39 2.30 ± 3.51 0.001*
b
0.000*
Fränkel n = 20 393.55 ± 5.34 395.70 ± 4.17 2.15 ± 2.66 0.733 0.901 c 0.002*
0.313
Bionator n = 20 394.60 ± 5.67 395.35 ± 2.72 0.75 ± 4.66 0.481
S-Go/N-Me × 100 (%)
M block n = 30 65.05 ± 3.78 65.14 ± 3.50 0.09 ± 1.34 0.711
b
0.441
Fränkel n = 20 65.31 ± 3.17 65.05 ± 3.07 -0.26 ± 1.70 0.590 0.384 c 0.505
0.656
Bionator n = 20 64.15 ± 4.28 63.83 ± 3.77 -0.32 ± 2.23 0.524
*statistically significant difference; amonofactorial variance analysis; btwo-factor analysis of the variance, factor time; ctwo-factor analysis of the variance, factor time
* group; dt-test for paired samples

Table 7. Values and statistical significance of the incisor position parameters

Significancea Significancea Significancee Significancee
T1 T2 Δ (T2 - T1) (difference (difference (difference (difference
Parameter Significanceb/c Significanced
x ± SD x ± SD x ± SD between between between between
groups T1) groups T2) groups T1) groups T2)
I/SpP (°)
M block n = 30 66.83 ± 4.13 71.33 ± 3.71 4.50 ± 2.27 0.000* 0.008* M vs. F
b
0.000*
Fränkel n = 20 70.10 ± 2.98 70.90 ± 3.07 0.80 ± 1.23 0.006* 0.904 c
0.009* 0.059 M vs. B
0.000*
Bionator n = 20 69.35 ± 3.43 71.15 ± 3.01 1.80 ± 1.23 0.000* 1.000 F vs. B
i/MP (°)
M block n = 30 87.15 ± 4.34 85.76 ± 3.77 -1.38 ± 1.91 0.000* 0.041* M vs. F 0.016* M vs. F
b
0.000*
Fränkel n = 20 89.75 ± 2.81 88.30 ± 2.53 -1.45 ± 1.27 0.029* 0.001* c
0.000* 0.166 M vs. B 0.001* M vs. B
0.013*
Bionator n = 20 89.15 ± 2.79 89.00 ± 2.17 -0.15 ± 1.23 0.591 1.000 F vs. B 1.000 F vs. B
a b c
*statistically significant difference; monofactorial variance analysis; two-factor analysis of the variance, factor time; two-factor analysis of the variance, factor time
* group; dt-test for paired samples; eBonferroni test

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154
ance analysis showed statistically significant differences
between groups before treatment, while in post-treatment
records significance appeared when comparing the M
block appliance with the Fränkel functional regulator,
and the M block appliance with the bionator. Two-factor
analysis of the variance with repeated measuring recog-
nized statistically significant changes in the i/MP values
after treatment, as well as significant differences between
groups over time (Table 7).
DISCUSSION
Growth modification treatment improves jaw relations,
resulting in a positive effect on dental structures’ relations.
Changes that happen during the functional appliance
treatment are a result of the synergy between the appli-
ance effects and growth that would happen regardless of
treatment. The aim of this study was to determine and
compare sagittal and vertical changes that occurred during
the M block appliance, Fränkel functional regulator type I,
and Balters’ bionator type I treatment. Patients diagnosed
with skeletal distal bite caused by mandibular prognathism
and in the prepubertal growth spurt period treated at the
Department of Orthodontics, Faculty of Dental Medicine,
University of Belgrade, were involved in this research. The
patients were divided into three groups according to the
type of appliance used: Group I treated with the M block
appliance, Group II treated with the Fränkel functional
regulator, and Group III treated with the Balters’ bionator.
This was done in order to compare the effects of different
types of functional appliances used in Class II treatment.
Our results indicate an insignificant decrease in the
SNA angle after M block and Fränkel functional regulator
treatment, and a significant increase after bionator treat-
ment. SNB and SNPg angles increased significantly in all
three groups. All this resulted in the ANB angle decrease.
Mandibular advancement with or without SNA angle
decrease is a quintessential part of functional appliance
treatment. As stated previously, the M block appliance
construction and treatment principles are similar to those
of the Sander’s appliance. Sander [7] and Sander et al. [11]
reported mesial mandibular movement and maxillary
growth inhibition (similar to the high-pull headgear ef-
fect) as results of his bite-jumping appliance treatment and
stressed that this kind of maxillary response could only be
achieved with one other appliance – the Herbst appliance.
A decrease in the SNA angle after bionator treatment was
noted by Moreira Melo et al. [12], while Almeida et al. [13]
found no differences between the bionator treated group
and the control group. Almeida et al. [13] also found sig-
nificant increase in the SNB angle after bionator treatment.
Comparing patients treated with the Sander appliance and
untreated Class II controls, Sander and Wichelhaus [6]
established significant increase of the SNB angle in treated
patients. Comparing the bite-jumping appliance, Fränkel
functional regulator, and bionator treated patients, Sander
and Lassak [14] found significantly greater skeletal effects
after bite-jumping appliance treatment, which led to me-
DOI: https://doi.org/10.2298/SARH170428146R
Ristić V. et al.
sial mandibular movement, maxillary growth inhibition,
and ANB angle decrease.
The fundamental question, “Do functional orthodontic
appliances stimulate additional mandibular growth?” still
remains unanswered. Results obtained in this study indi-
cate an increase in the length of maxillary and mandibular
bodies in all three groups, regardless of the type of appli-
ance used. Total mandibular length increased significantly
after M block and Fränkel functional regulator treatment,
while the bionator group lacked significance.
In their meta-analysis from 2006, Cozza et al. [15] ana-
lyzed papers dealing with mandibular changes after func-
tional Class II treatment. In more than half of the papers
analyzed, researchers had found clinically significant man-
dibular growth as a result of functional appliance treat-
ment, and this growth was significantly greater if patients
were treated at an appropriate age, i.e. during the pubertal
growth spurt. However, none of the randomized clinical
studies established clinically significant growth as a result of
functional appliance treatment. This is in line with the find-
ing of dos Santos-Pinto et al. [16], who compared bionator
treated patients with untreated controls and found signifi-
cant growth in both groups, regardless of whether they were
treated or not. On the other hand, Moreira Melo et al. [12]
found an increase in total mandibular growth after biona-
tor treatment, which was confirmed by Almeida et al. [13],
who reported significant increase in the length of mandibu-
lar corpus and total mandibular length. Class II functional
treatment using the bionator was also examined by Malta
et al. [17], who found favorable skeletal and dental changes
at the end of treatment, specifically significant increase in
mandibular corpus length. Martina et al. [18] reported sig-
nificant improvement in sagittal inter-maxillary relations
after bite-jumping appliance treatment, primarily due to the
actual increase in mandibular corpus length and minimal
maxillary growth restriction. Freeman et al. [19] examined
the effects of the Fränkel functional regulator and found the
greatest long-term effects had been achieved at the level of
sagittal maxillo-mandibular relations, with minimal maxil-
lary growth inhibition. In their meta-analysis, Perillo et al.
[20] analyzed studies that examined the effects of the Frän-
kel functional regulator. Even though the research included
was very heterogeneous, all authors stressed the positive
effect of the Fränkel functional regulator on mandibular
growth, especially total mandibular length, clinical effect re-
ported being minimal to moderate. Another meta-analysis
by Marsico et al. [21] analyzed the therapeutic effects of
the Fränkel functional regulator, bionator and several other
functional appliances. All authors of included studies re-
ported statistical significance of skeletal changes, but stated
lack of their clinical significance. Even though this supports
the claims that two-phase treatment has no advantages over
one-phase treatment, Marsico et al. [21] stress the benefits
of using functional appliances in the first phase of Class II
treatment. Some of the advantages they mention are preven-
tion of maxillary incisor trauma due to increased overjet,
interception of dysfunction, psycho-social benefits for the
growing child, stable dentoalveolar correction, and shorter
treatment time with fixed orthodontic appliances.
Srp Arh Celok Lek. 2018 Mar-Apr;146(3-4):149-156
Effects of three types of functional appliances in Class II malocclusion treatment – sagittal and vertical changes
Looking at vertical parameters, the results of our study
indicate an increase after M block and bionator treatment,
while Fränkel functional regulator resulted in insignificant
clockwise rotation of the maxilla and counter-clockwise
rotation of the mandible. This led to a decrease in the
maxillo-mandibular vertical angle after Fränkel functional
regulator, and its increase after M block and bionator treat-
ment. The Björk–Jarabak analyses revealed neutral growth
in all groups at the end of treatment.
Malta et al. [17] also found an increase in vertical di-
mensions after bionator treatment, while Martina et al.
[18], who examined the effects of the Sander bite-jumping
appliance, and Freeman et al. [19], who analyzed the Frän-
kel functional regulator effects, concluded the unwanted
clockwise rotation of the maxilla and mandible was both
clinically and statistically insignificant. The important
thing to consider here is the type of facial growth and
vertical parameter values before treatment. Most patients
from our sample were horizontal growers according to
the Björk–Jarabak analyses, so the increase of the Björk
polygon sum of angles led to neutral growth at the end
of treatment.
Finally, incisor position parameters in this study’s
sample indicate upper incisor retrusion and lower inci-
sor protrusion in all three groups at the end of treatment.
Even though it was statistically significant, upper incisor
retrusion was clinically insignificant in groups treated with
the Fränkel functional regulator and bionator, while it was
clinically significant in the M block-treated group. Lower
incisor protrusion was clinically insignificant in all three
groups at the end of treatment.
In Class II, Division 1 patients, overjet is typically in-
creased due to upper incisor protrusion [2]. Upper incisor
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at the end of Sander’s bite-jumping appliance treatment.
CONCLUSION
The results of our study indicate efficiency in skeletal
Class II malocclusion treatment of all three types of func-
tional appliances (M block appliance, Fränkel functional
regulator type I, and Balters’ bionator type I) investigated.
Owing to significant mesial positioning and mandibular
sagittal growth, sagittal maxillo-mandibular angle values
decreased. Upper incisor retrusion and lower incisor pro-
trusion additionally decreased the overjet. All three types
of appliances produced neutral facial growth in patients
at the end of treatment. Our results indicate all three types
of functional appliances are suitable for skeletal Class II
malocclusion treatment of growing patients in everyday
clinical practice.
NOTE
This paper is based on Dr. Vladimir Ristić’s PhD thesis.
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www.srpskiarhiv.rs
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Терапијски ефекти три врсте функционалних апарата у лечењу малоклузија II
скелетне класе – сагиталне и вертикалне промене
Владимир Ристић, Неда Љ. Стефановић, Зорана Стаменковић, Марија Живковић-Сандић, Вања Стојић, Бранислав
Глишић
Универзитет у Београду, Стоматолошки факултет, Клиника за ортопедију вилица, Београд, Србија
САЖЕТАК
Увод/Циљ рада Малоклузије II класе су сагиталне неправил-
ности загрижаја које карактерише дистални однос бочних
зуба. У зависности од тога које структуре су у неправилном
односу, деле се на скелетне и дентоалвеоларне. Терапија II
класе зависи од узрока, изражености и узраста. Најбољи
вид терапије уколико пацијенти и даље расту је модифи-
кација раста.
Циљ ове студије био је да се утврде и упореде сагиталне и
вертикалне промене на скелетним и денталним структурама
у току лечења М блок-апаратом, Френкловим регулатором
функције тип I и бионатором по Балтерсу тип I.
Методе Седамдесет испитаника са дијагнозом скелетног
дисталног загрижаја (ANB > 4°) и мандибуларног ретрогна-
тизма (SNB < 80°), према врсти апарата, подељени су у три
DOI: https://doi.org/10.2298/SARH170428146R
Ristić V. et al.
biteplane and bionator appliances. Am J Orthod Dentofacial
Orthop. 2007; 132(2):191–8.
23. Siara-Olds NJ, Pangrazio-Kulbersh V, Berger J, Bayirli B. Long-Term
Dentoskeletal Changes with the Bionator, Herbst, Twin Block, and
MARA Functional Appliances. Angle Orthod. 2009; 80(1):18–29.
24. Stamenković Z. Primena Frenklovih regulatora funkcije kod
skeletno distalnog zagrižaja. Belgrade: Zadužbina Andrejević; 2012.
25. Šćepan I. Efekti terapije malokluzija II klase funkcionalnim
aparatima [dissertation]. Belgrade: University of Belgrade; 1997.
групе. Сви су прошли кроз стандардну дијагностику (анам-
неза, клиничка и функционална анализа, анализа студијских
модела, ортопантомографског и профилног телерендген-
ског снимка). Терапијски ефекти и промене анализирани
су на студијским моделима и профилном снимцима по за-
вршетку терапије.
Резултати Сва три апарата довела су до значајног ме-
зијалног усмеравања и сагиталног раста мандибуле, што
је смањило ANB угао. У све три групе је утврђен неутрални
раст, као и ретрузија горњих и протрузија доњих секутића.
Закључак Резултати студије указују на ефикасност сва три
испитивана апарата у лечењу скелетних малоклузија II класе.
Кључне речи: малоклузије II класе; функционална терапија;
М блок; Френклов апарат; бионатор
Srp Arh Celok Lek. 2018 Mar-Apr;146(3-4):149-156